1. HFAP 2018 Medical Staff Standards
Karen Beem, MS, RN
HFAP Standards Interpretation

2. 2018 What’s New? Chapter 3 Medical Staff 11/16/201811/16/2018
HFAP │ National Credentialing Forum

3. What’s New for 2018? No New Medical Staff Requirements 11/16/2018
HFAP │ National Credentialing Forum

4. Top Cited Deficiencies
Chapter 3 Medical Staff
2017
Top Cited Deficiencies
11/16/201811/16/2018
HFAP │ National Credentialing Forum

5. Condition of Participation 03.00.00 Medical Staff
CMS Requires…
The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. §482.22
11/16/2018
HFAP │ National Credentialing Forum

6. Condition of Participation
Medical Staff §482.22
Condition-level Citations:
One (1) GI Proceduralist lacked privileges for moderate sedation
Four (4) Physician Assistants lacked privileges – facility allowed PAs to function under “State Scope of Practice”
11/16/2018
HFAP │ National Credentialing Forum

7. Standard-level Citation
Medical Staff Recommendations to Governance:
Standard-level Citations:
Privileges exceed 24 months
Lack evidence of Medical Staff recommendations to the Governing Body
11/16/2018
HFAP │ National Credentialing Forum

8. 2017 Challenges Chapter 3 Medical Staff 11/16/201811/16/2018
HFAP │ National Credentialing Forum

9. 03.15.01 OPPE 03.15.01 OPPE Standard-level Citations:
OPPE not addressed in Bylaws
OPPE data not considered with re-appointment
Failure to identify OPPE performance indicators (non-physician practitioners):
Nurse Practitioners
Physician Assistants
11/16/2018
HFAP │ National Credentialing Forum

10. 03.15.02 FPPE 03.15.02 FPPE Standard-level Citations:
FPPE not addressed in Bylaws
FPPE process not communicated to individual with initial appointment
Failure to identify FPPE performance indicators (non-physician practitioners):
Nurse Practitioners
Physician Assistants
11/16/2018
HFAP │ National Credentialing Forum

11. 2018 Retired Standards Chapter 3 Medical Staff 11/16/201811/16/2018
HFAP │ National Credentialing Forum

12. Retired Standards
– Utilization of Osteopathic Methods & Concepts Committee
11/16/2018
HFAP │ National Credentialing Forum

13. THANK YOU
Office:
11/16/201811/16/2018
HFAP │ National Credentialing Forum